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A nurse is evaluating a postpartum client for potential endometritis.
Which of the following symptoms should the nurse identify as a need for further assessment?

Hematuria

Pelvic pain

Moderate amount of dark red lochia with a bloody odor

Localized area of breast tenderness

Answer and Explanation

The Correct Answer is B

Choice A rationale

Hematuria, or blood in the urine, is not typically a symptom of postpartum endometritis.

Choice B rationale

Pelvic pain is a common symptom of postpartum endometritis. It is often one of the first symptoms to appear, along with lower abdominal pain and uterine tenderness.

Choice C rationale

While a moderate amount of dark red lochia with a bloody odor can be a normal part of the postpartum period, it is not specifically indicative of endometritis.

Choice D rationale

Localized area of breast tenderness is not typically a symptom of postpartum endometritis.

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Correct Answer is C

Explanation

Choice A rationale

Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.

Choice B rationale

Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.

Choice C rationale

Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.

Choice D rationale

Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.

A. Call the Doctor. B. Administer diazepam. C. Obtain a medical history. D. Raise the side rails of the bed.

Correct Answer is B

Explanation

Choice A rationale

While it is important to notify the doctor, it is not the first action. The priority is to manage the patient’s symptoms and ensure their safety.

Choice B rationale

Administering diazepam is the correct first action. Delirium tremens is a severe form of alcohol withdrawal that can cause dangerous changes in breathing, blood pressure, and heart rate. Benzodiazepines like diazepam are the first line of treatment.

Choice C rationale

Obtaining a medical history is important, but it is not the first action. The priority is to treat the patient’s symptoms and stabilize their condition.

Choice D rationale

Raising the side rails of the bed is important for patient safety, but it is not the first action. The priority is to treat the patient’s symptoms. Diabetic ketoacidosisDiabetic ketoacidosis Explore

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A nurse is evaluating a postpartum client for potential endometritis.Which of the following symptoms should the nurse identify as a need for further assessment?

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Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient who is in active labor and recognizes late decelerations on the fetal monitor.The healthcare provider has been informed.What is the nurse’s priority action?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A nurse is evaluating a postpartum client for potential endometritis.
Which of the following symptoms should the nurse identify as a need for further assessment?